Patient safety goal 4 : Tackling Antimicrobial Resistance

To implement WHO’s 3rd
Global
Patient Safety Challenges-
“Tackling Antimicrobial Resistance”
Patient Safety Goal (PSG) No 4
1PSG4 :Tackling Antimicrobial Resistance

WHO 3rd
Global Patient Safety Challenge:
Tackling Antimicrobial Resistance
RATIONALE
Antimicrobial resistance poses a
growing threat to the treatment and
control of infections

Antimicrobial misuse puts community at risk of
severe illness / death due to untreatable infections,
and
wastes limited healthcare resource for future
generations.
HAI with MDRO are major causes of death in the
world.
Inappropriate use of antimicrobials by patients,
healthcare providers, and food producers is an issue of
patient safety.
PSG 4: Tackling Antimicrobial Resistance

Antibiotic exposure increases the
risks of resistance
Pathogen and Antibiotic Exposure Increased Risk
Carbapenem Resistant Enterobactericeae
and Carbapenems
15 fold
ESBL producing organisms and Cephalosoprins 6- 29 fold
Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
Zaoutis TE et al. Pediatrics 2005;114:942-9
Talon D et al. Clin Microbiol Infect 2000;6:376-84
More usage,
more
resistance!!

Increasing resistant rate of E.coli &
K.Pneumo to 3rd
GEN cephalosporins
Institute for Medical
Research

MultiDrug Resistant Organism
(MDRO)
MDRO (MultiDrug-Resistant Organism) :
microorganisms, predominantly bacteria, that are
resistant to one or more classes of antimicrobial
agents.

Must fulfill all 3 criteria:
i. Isolation of an MDRO from any body sites
ii. The patient must be admitted to the ward
iii. The case must be “Newly Identified”
“Newly identified” include:
i. MDRO identified for the first time during current
hospital admission
ii. Cases that have been identified at our site but acquired
“new infection “
( Infection with organism having different antibiogram
0r as defined “new infection” by clinician)
Definition: MDRO Case
8
PSG4 :Tackling Antimicrobial Resistance

• Population under surveillance : all in patients
• Exclusion:
i.Cases from Emergency department, clinic, or other
outpatient services
ii.Cases previously identified at other acute care
facilities/hospitals
iii.Cases re-admitted with same MDROs within one
year
iv.Cases with insufficient information on healthcare
exposure
v.Cases from screening culture
vi.Coloniser
PSG 4:Tackling Antimicrobial Resistance- Methodology
9

Indicators 1.Incidence rate of MRSA
infection
2. Incidence rate of ESBL-
Klebsiella Pneumoniae infection
3. Incidence rate of ESBL-E.coli
infection
- 3 Indicators

Indicators 1.Incidence rate of MRSA infection
Type of
Indicator
Outcome indicator
Numerator
(N)
Number of MRSA infection (new
cases) in the hospital
Denominator
(D)
Total number of hospital admissions
Formula (N/D) x 100
Target ≤ 0.4%
1.Incidence rate of MRSA infection

MRSA
(Methicillin-resistant Staphylococcus Aureus )
MRSA : a bacteria that is resistant to
many antibiotics.
In the community, most MRSA
infections are skin infections.
In medical facilities, MRSA causes life-
threatening bloodstream infections,
pneumonia and surgical site infections.
12

Indicators 2) Incidence rate of ESBL- Klebsiella
Pneumoniae infection
Type of
Indicator
Outcome indicator
Numerator
(N)
Number of patients with ESBL-
Klebsiella Pneumoniae infection (new
cases) in the hospital
Denomina
tor (D)
Formula (N/D) x 100
Target ≤ 0.3% 13
Extended-Spectrum β-Lactamases (ESBLs)
Klebsiella Pneumoniae

Indicators 3) Incidence rate of ESBL-E.coli infection
Type of
Indicator
Outcome indicator
Numerator
(N)
Number of ESBL-E.coli infection (new cases) in
the hospital
Denominator
(D)
Formula (N/D) x 100
Target ≤ 0.2%
Data
collection at
facility level
Monthly
Reference Alert Organism Surveillance Manual, MOH 2012
14

ESBL (Extended-Spectrum β-Lactamases)
 Are enzymes that mediate resistance to
extended-spectrum (3rd generation)
cephalosporins (e.g., ceftazidime, cefotaxime,
and ceftriaxone) and monobactams (e.g.,
aztreonam).
• Why should clinician be concerned about
detecting ESBL?
Presence of an ESBL-producing organism in a
clinical infection can result in treatment failure if
one of the above classes of drugs is used.
15

• Meta-analysis of
mortality in ESBL-
producing versus
non-ESBL-producing
Enterobacteriaceae
bacteraemia
• Having an ESBL
bacteraemia
confers almost
2x risk of dying
compared to a
non-ESBL
bacteraemia !!
•The pooled RR, represented by the diamond at the bottom of the figure, is 1.85 (95% CI 1.39–2.47, P , 0.001).
•There was significant heterogeneity among the study results (P = 0.001).
Journal of Antimicrobial Chemotherapy (2007) 60, 913–920.
Mortality Associated with ESBL-Producing
Bacteremia

What happens when antibiotics no
longer work?
<20% chance of survival in
pneumococcaemia if no antibiotic is
available for treatment !! 17PSG4 :Tackling Antimicrobial Resistance

“Tackling Antimicrobial Resistance”
18
Strategies & Implementation
1.Implement Malaysia National Antibiotic
Guidelines
2.National & State campaign on containment
of Antimicrobial resistance
3.Antibiotic Stewardship Programme

Benefits of prudent use of antibiotics
• Prudent use of antibiotics can prevent the emergence and selection of
antibiotic-resistant bacteria.19-23
• Decreasing antibiotic use have also been shown to result in lower
incidence of Clostridium difficile infections.24-26
Rates of Vancomycin-resistant Enterococci in hospital
before and after implementation of the antibiotic
management program compared with rates in
National Nosocomial Infections Surveillance (NNIS)
System* hospitals of similar size.27
*NNIS is now the National Healthcare Safety Network
(NHSN).
Rates of nosocomial Clostridium difficile, expressed
per 1,000 patient-days, before and after
implementation of the antibiotic management
program.28
19, 24. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane
Database Syst Rev. 2005(4):CD003543.
20. Lepper PM, Grusa E, Reichl H, Hogel J, Trautmann M. Consumption of imipenem correlates with beta-lactam resistance in Pseudomonas aeruginosa. Antimicrob
Agents Chemother. 2002 Sep;46(9):2920-5.
21, 25, 27, 28. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect
Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
22. Bradley SJ, Wilson AL, Allen MC, Sher HA, Goldstone AH, Scott GM. The control of hyperendemic glycopeptide-resistant Enterococcus spp. on a haematology
unit by changing antibiotic usage. J Antimicrob Chemother.
23. De Man P, Verhoeven BAN, Verbrugh HA, Vos MC, Van Den Anker JN. An antibiotic policy to prevent emergence of resistant bacilli. Lancet. 2000;355(9208):973-

Antimicrobial Stewardship
Programme
• Promotes appropriate use of antimicrobials by
selecting
– Appropriate indication
– Dose
– Duration
– Route of administration.
• Has potential to
– Improve efficacy
– Minimize drug-related adverse events
– Limit the emergence of antimicrobial resistance
– Reduce treatment-related costs.
Multidisciplina
ry; teamwork
essential!

Remember
to USE
guidelines

Stewardship optimizes
patient safety: decreased
patient-level resistance
Evaluat
e at 3
days
Standar
d care
Antibiotic
duration
3 days 10 days
LOS ICU 9 days 15 days
Antibiotic
resistance/
superinfect
ion
14% 38%
Study terminated early because
attending physicians began to treat
standard care group with 3 days of
therapySingh N et al. Am J Respir Crit Care Med.
2000;162:505-11.
72 hour
re-
evaluati
on
works!!

 A positive culture from a sterile site (blood,
CSF, pleural fluid, peritoneal fluid) unless
determined to be contaminant
OR
 A positive culture for the selected organisms
isolated from a non-sterile site isolate AND
presence of clinical signs and symptoms OR
determined by attending physician
Infection

Data Collection
 Infection Control Personnel (ICP) shall collects
data on MDRO on a daily basis from the
laboratory.
 The ICP will liaise with staff in the relevant
clinical area to ensure that the infection
control practices are implemented.

Cont - Data Collection
 Upon isolation of MDRO, the ICP should
investigate and complete the MDRO
Surveillance Form and Line-listing Form
 The specific type of infection is determined
based on the CDC/NHSN Surveillance
Definition of Healthcare-Associated Infection
and Criteria for Specific Types of Infections in
the Acute Care Setting.

Numerator
MDRO from HCAI cases, own facility
Denominator
The classification of infection in relation to the
health care facility is detailed in appendix 1
Data Analysis And Reporting

Appendix 1Classification Of MDRO Infection In Relation To The
Healthcare Facility

RATE = Total no. of HCAI cases x 100%
Total admission of the month
Data Analysis And Reporting

SUMMARY
Patient Safety Goal No 4

To implement WHO’s 3rd
Global
Patient Safety Challenges-
“Tackling……………………………………”
Patient Safety Goal No 4

Indicators 1.Incidence rate of
……..infection (< 0.4%)
………………infection (< 0.3%)
……….. infection (< 0.2%)
3 Indicators :Patient Safety Goal No 4

Thank YouThank You 37PSG4 :Tackling Antimicrobial Resistance

Patient safety goal 4 : Tackling Antimicrobial Resistance

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Patient safety goal 4 : Tackling Antimicrobial Resistance